Chapter 24 of 31 · 2343 words · ~12 min read

CHAPTER VIII

NARCOTIC POISONS

Somniferous

OPIUM

Opium is the inspissated juice of the _Papaver somniferum_, the garden or opium poppy. The plant is a native of Egypt and Syria, cultivated in England.

Opium is sometimes taken in its crude state as a poison, but more frequently one of its preparations is thus employed--notably the tincture, better known as laudanum.

The poisonous properties of this drug reside in an alkaloid, _morphine_--in combination with an acid, _meconic acid_. The several varieties of opium vary considerably in the quantity of morphine which they contain, the amount varying from 2 to 9 per cent.

Opium, or its alkaloid, morphine, forms an important ingredient in _Dalby‘s Carminative_, _Winslow‘s Soothing Syrup_, _Godfrey‘s Cordial_, _Chlorodyne_, _Nepenthe_, &c.

Of all forms of poisoning, that by opium and its preparations is the most frequent; and it is stated that three-fourths of all the deaths from opium occur among children _under five years of age_.

_Symptoms._--The rapidity with which the symptoms of poisoning by opium make their appearance will depend upon the form in which the poison is taken--solution, of course, increasing the activity of the drug. In most cases, an interval of from half an hour to an hour elapses after the poison has been swallowed before any evil effects become apparent. Christison, however, mentions a case in which stupor did not show itself for eighteen hours. During the first stage of poisoning by opium, the patient may become slightly excited; this state is, however, soon followed by giddiness and drowsiness. The eyes are kept open with difficulty. Stupor and insensibility now supervene, from which he may, in most cases, be temporarily aroused by a loud noise or a smart blow. As the case progresses, coma and stertorous breathing occur, and it becomes almost impossible to rouse him at all. The pulse, at first small, quick, and irregular, becomes slow and full as the coma increases. The breathing, hurried in the early stages, is now slow and stertorous. The pupils are contracted in the early stages, and may be in the later stages dilated; the former condition is most frequently present, together with insensibility to light. The pupils may be contracted in cases of _hæmorrhage into the pons Varolii_, and this disease has been mistaken for opium poisoning. In uræmic coma, coming on in the course of Bright‘s disease, the pupils may also be contracted; the nature of the case will be explained by the history and presence of dropsy. All the secretions, except that of the skin, are suspended, and the bowels are usually obstinately confined. The breath may be impregnated with the odour of opium. Certain anomalies in the symptoms may occur; thus, there may be vomiting and purging, convulsions (the last most frequent in children), delirium, tetanic spasms, one pupil dilated and the other contracted, paralysis, and anæsthesia. It must be borne in mind that remissions sometimes occur in the symptoms, the patient dying after an attempt at recovery.

A question of some importance may arise as to the amount of volition and power of locomotion which may exist for some time after a poisonous dose has been taken. Death may be due to causes other than the effect of poison. It must, at least, be admitted as possible, that a person, after swallowing a quantity of opium sufficient to cause death, may yet be able to walk and move about for one or two hours.

_Opium-eating._--If opium be taken for some time in small doses, the system becomes tolerant of it, so that a dose which would be poisonous to most people only produces a slight and pleasurable excitement. De Quincey was in the habit of taking daily nine ounces of laudanum. The habitual opium-eater generally suffers from disorders of the digestive organs, dyspepsia and its train of unpleasant symptoms; the body becomes thin, the countenance attenuated, the eyes sunken and glassy, the gait halting, and the body bent. The craving for the drug, which becomes greater and greater, is only temporarily satisfied by larger and larger doses. The opium-eater seldom attains a great age, usually dying before forty. This is perhaps a somewhat exaggerated picture of the ill effects of opium-eating. Christison, after quoting the results of his observations in twenty-five cases of confirmed opium-eaters, concludes as follows: “These facts tend on the whole rather to show that the practice of eating opium is not so injurious, and an opium-eater‘s life is not uninsurable, as is commonly thought, and that an insured person, who did not make known his habit, could scarcely be considered guilty of concealment to the effect of voiding his insurance. But I am far from thinking (as several represent who have quoted this work) that what has now been stated can with justice be held to establish such important inferences; for there is an obvious reason why, in an inquiry of this kind, those instances chiefly should come under notice where the constitution has escaped injury--cases fatal in early life being more apt to be lost sight of, or more likely to be concealed.”

_Effects of External Application._--The application of opium to the surface of the body is not usually attended with dangerous symptoms; but, in a few cases, due probably to some idiosyncrasy, alarming effects, or even death, have resulted from the external application of the drug. Orfila has tried to show that opium is readily absorbed by the coats of the rectum, and that it acts more rapidly than when taken into the stomach. This statement does not appear to be correct, for the dose administered by enema is usually twice that given by the mouth.

_Post-mortem Appearances._--As might be expected, the appearances found after death are not very characteristic. The vessels of the brain are congested, and serous effusions in the ventricles or between the membranes are not uncommon. Engorgement of the lungs is most frequently present in those cases in which convulsions have occurred. The stomach is in most cases found quite healthy. The bladder may be full of urine, due probably to the person being unable to empty it from loss of consciousness.

_Fatal Period._--From three-quarters of an hour and upwards.

_Fatal Dose._--Four grains is about the smallest fatal dose of opium in an adult; but cases of recovery, where an ounce or more of laudanum has been taken, are not very rare. Children are very susceptible to opium. The smallest dose of morphine that has proved fatal to an infant is one-twelfth of a grain of the hydrochloride. Half a grain of the acetate has proved fatal to an adult, one grain of morphine or its salts has proved fatal on several occasions. With prompt treatment recovery has taken place after much larger doses, even as much as seventy-five grains.

_Chemical Analysis and Tests._--These have been described on p. 339 _et seq._

_Treatment._--The stomach pump should be used without delay, and the stomach thoroughly washed out. The washing water should contain about ten to fifteen grains of permanganate of potash to the pint, and the washing repeated at short intervals, as the permanganate destroys the morphine. If the stomach tube be not at hand, the patient should be made to drink the permanganate solution if possible. This treatment should be carried out even when morphine has been administered hypodermically, as it is excreted by the stomach. Emetics should also be given if the patient can swallow; if unable to do so, a hypodermic of ⅒ grain of apomorphine may be given. The administration of strong coffee or tea, the application of ammonia to the nostrils, flagellation of the soles of the feet, and keeping the patient constantly walking about (a procedure of doubtful value) are among the measures usually adopted by way of treatment. Galvanism and artificial inflation of the lungs have done good service even in the most hopeless cases. The student is referred to some important cases recorded by Dr. Burgess and others in the _Medical Press and Circular_, vol. i. p. 369, for the year 1892. Dr. Burgess strongly recommends prolonged artificial respiration, the interrupted current, and the administration of stimulants, externally, internally, and hypodermically. Dr. Finny is of opinion that, while opium may be useful in cases of atropine poisoning, atropine is of little use in opium poisoning; in this opinion Dr. Burgess concurred. The state of the respiration is a better test than the condition of the pupil when atropine is used as an antidote. If the administration of atropine does not quicken the respiration it should be discontinued, and other methods tried. Vinegar should not be given, as it dissolves the morphine and renders it more easy of absorption. Death is rare in those cases in which proper remedies have been resorted to before the stage of stupor has commenced.

=Synopsis of the Effects of Opium upon the System=

1. _The Mental Faculties._--The first effect noticed when opium is taken in small doses is a primary exaltation of the mental faculties; the imagination is rendered brilliant, and the passions exalted; after a time drowsiness supervenes, followed by deep sleep. A dose of thirty drops of the tincture caused in one experimenter an exhilaration of the mental faculties, and an aptitude for study; the subsequent drowsiness being removed by a dose of a hundred drops or more, when the greatest mental excitement was the result.

2. _The Respiration._--The frequency of the respiration is diminished, and the oxidation of the blood impaired.

3. _The Pulse._--The first effect on the circulatory system is that of a stimulant, and then sedative. By the administration of repeated small doses, the force of the circulation may be maintained for some time.

4. _The Eyes and Countenance._--The pupils, when the patient is powerfully under the influence of opium, are contracted even to a point. Dilatation, has, however, been noticed in some cases, especially when death approaches. In apoplexy of the pons Varolii, the pupils are contracted. The countenance is placid, pale, and ghastly; the eyes heavy, and the lips livid.

5. _The Cutaneous System._--The skin, although cold, is not infrequently bathed in profuse perspiration.

6. _The Alimentary Canal._--Sometimes there is vomiting and even purging; but, as a rule, the secretions along the whole alimentary canal are diminished, and constipation is the result. According to Dr. Walter Smith, of Dublin, morphine is mainly excreted into the stomach and bowels, and so cast out in the fæces. Very little goes out in the urine.

7. _The Average Commencement of Symptoms._--Much depends upon the size and form of the dose. In most cases the first appearance of the symptoms is seldom delayed beyond an hour after the poison is taken.

8. _The Average Period of Death._--Seven to twelve hours.

Table showing some of the Symptoms and Effects of Opium and Belladonna ---------------------------------+----------------------------------- Opium. | Belladonna. ---------------------------------+----------------------------------- 1. Slight excitement, coma, | 1. Active, busy delirium preceding lethargy, and no return of the | the coma, followed by delirium, excitement should the patient | if recovery takes place. recover. | | 2. Coma is of shorter duration | 2. Coma is of longer duration than in poisoning by belladonna.| than in poisoning by opium. | 3. Pupils contracted. | 3. Pupils dilated. | 4. Local application to the eye | 4. Dropped into the eye, the does not affect the pupil. | pupils are dilated. | 5. Bowels as a rule confined. | 5. Bowels not affected. | 6. Acts powerfully on children. | 6. Well borne by children. ---------------------------------+-----------------------------------

Table showing the Points of Distinction between Apoplexy and Narcotic Poisoning

------------------------------------+-------------------------------- Apoplexy. | Narcotic Poisoning. ------------------------------------+-------------------------------- 1. Apoplexy _may_ be preceded by | 1. No premonitory symptoms, premonitory symptoms, as giddiness,| except by fortuitous headache, noises in the ears, | combination. and partial paralysis. | | 2. Apoplexy chiefly attacks the | 2. More frequently in the old, and is very rare in young | young, especially of the people. | female sex. | 3. Most frequently among fat | 3. In fat or thin people. people. | | 4. Symptoms may come on during | 4. An interval of from ten to the meal or _immediately_ after. | thirty minutes always occurs, | even in the case of opium, the | commonest of narcotic poisons. | 5. The symptoms commence abruptly, | 5. The symptoms advance sometimes with deep stupor. | gradually. | 6. Patient is with difficulty, if | 6. Patient may be roused from ever, temporarily aroused. | the deepest lethargy if shaken Convulsions common. Face bloated. | or spoken to in a loud voice. Pupils _dilated_, or irregular. | Convulsions rare in opium | poisoning. Face seldom bloated. | Pupils _contracted_. | 7. Life may be prolonged for a | 7. Life is seldom prolonged day or more. Apoplexy _may_, | beyond six or eight hours. however, kill in an hour. | Shortest time in which opium | has caused death, _three_ | hours. | 8. No response when the forehead | 8. Patient may be roused by is smartly tapped with the | tapping the forehead, &c. finger-nails, or when water is | injected into the ear. | ------------------------------------+--------------------------------